Tuesday, December 28, 2010

Wikileaks document on Cuban health care

Thursday, 31 January 2008, 19:52C O N F I D E N T I A L SECTION 01 OF 06 HAVANA 000103 SIPDIS SIPDIS DEPT FOR WHA/CCA EO 12958 DECL: 01/25/2018 TAGS PGOV, PINR, PREL, ECON, AMED, SOCI, AMGT, CU SUBJECT: CUBAN HEALTHCARE: “AQUI NADA ES FACIL” (HERE NOTHING IS EASY)REF: HAVANA 0076Classified By: COM: Michael E. Parmly: For reasons 1.4 b/d¶1. (C) SUMMARY: This cable is a follow up to Reftel and provides anecdotal accounts from Cubans about their healthcare, based on USINT FSHP’s (Foreign Service Health Practitioner) interactions with them, her unauthorized visits to Cuban hospitals, and her care of USINT American and Cuban personnel. End Summary.¶2. (C) The following anecdotes were obtained from Cubans of various walks of life: domestic employees, neighbors in the Havana suburbs, USINT Local Contract National (LCN) employees, service providers such as manicurists, masseuses, hair stylists, chauffeurs, musicians, artists, yoga teachers, tailors, as well as HIV/AIDS and cancer patients, physicians, and foreign medical students.-- A Cuban woman in her thirties confides, “It’s all about who you know. I’m okay because I am healthy and I have ‘friends’ in the medical field. If I didn’t have my connections, and most Cubans do not, it would be horrible.” She relates that Cubans are increasingly dissatisfied with their medical care. In addition to the general lack of supplies and medicines, and because so many doctors have been sent abroad, the neighborhood family physicians now care for 300-400 families and are overwhelmed by the workload. (Note: Neighborhood doctors are supposed to provide care for only 120 families. End Note.) In the absence of the physicians, patients go to their municipality’s “polyclinic,” but long lines before dawn are common, with an all too common 30-second diagnosis of “it’s a virus.”-- A 40-year old pregnant Cuban woman had a miscarriage. At the OB-Gyn hospital they used a primitive manual vacuum to aspirate the contents of her womb, without any anesthesia or pain medicine. She was offered no emotional support for her ‘loss’ and no pain medication or follow up appointments.-- A 6-year old Cuban boy with osterosarcoma (bone cancer) is admitted to the oncology hospital. Only his parents are permitted to visit, and then only for limited hours. He does not have a television nor any games or toys. The hospital offers no social support services. The parents do not seem informed as to their son’s case. When asked by the FSHP what they know about the management of the disease, they shrug their shoulders. According to the FSHP, cancer patients do not receive on-going basic care utilizing testing procedures common in much of the world to monitor cancer care -- such as blood chemistries and tumor markers, sonograms, x-rays, CT and bone scans, MRIs, PET scans, etc. Patients are generally informed of the type of cancer they have, but know little of its staging, tumor size, metastasis, or prognosis. They may be offered surgery followed by chemotherapy and/or radiation but are not given choices to decide an aggressive versus less aggressive approach, nor are they allowed internet access to learn more of their disease.-- Many young cancer patients reportedly have become infected with Hepatitis C after their surgeries. Contracting Hepatitis C after surgery indicates a lack of proper blood screening prior to administering transfusions. All blood should be screened for Hepatitis B, C, HIV and Syphilis prior to use. Patients have no recourse and are not fully informed of the seriousness of such an inadvertent infection.-- During chemotherapy and radiation treatments, patients receive little in the way of symptom or side-effects care (i.e., severe nausea, vomiting, low blood counts, fever, diarrhea, radiation burns, mouth sores, peripheral neuropathies,etc.) that is critically important in being able to continue treatments, let alone provide comfort to an already emotionally distraught victim. Cancer patients are not provided with, nor can they find locally, simple medications such as Aspirin, Tylenol, skin lotions, vitamins, etc. Most Cuban patients are not offered Hospice Care or any social support programs for children, adults, or their care providers.-- HIV positive patients have had the letters ‘SIDA’ (AIDS)HAVANA 00000103 002 OF 006stamped on their national ID cards. Needless to say, in a country where the national ID card must be shown for everything from getting monthly rations to buying a train ticket, the person is stigmatized for life. There is no patient/doctor confidentiality and discrimination is very strong. (Note: According to Pan-American Health Organization (PAHO) officials in Havana, stamping ID cards used to be the case but is no longer the practice in Cuba, something we could not independently corroborate. End Note.)-- Some newly diagnosed HIV/AIDS patients are held in what has come to be known as “Prision de Pacientes con SIDA de San Jose” (Prison for AIDS patients). There they are started on antiretrovirals AZT, D4T, 3TC. It is unclear to them why they were put in this prison-like facility but believe it is plain discrimination due to their homosexuality. The average period spent at this facility seems to be 18-24 months.-- AIDS patients are not given prophylaxis medication for the prevention of PCP (Pneumocysti carinii pneumonia), and for lack of newer medicines some patients are re-started on antiretroviral regimens that were stopped due to significant side effects. The Cuban family physicians who care for these patients’ primary care needs do not have the authority to treat their HIV/AIDS disease. There is only one facility in Cuba, Instituto Pedro Kouri, located in Havana, where HIV positive patients can receive their specialty care, antiretroviral medications and treatments. According to HIV positive Cubans known to FSHP, one usually waits for months for an appointment, but can often move ahead in line by offering a gift or hard currency. We are told five Cuban convertible pesos (approximately USD 5.40) can get one an x-ray and more can get one a CD4 count. Patients on the island must travel to the capital city for their specialist visits and medication. Due to the lack of island-wide transportation and the cost of travel, many HIV-positive patients may be seen only once per year.-- While the GOC claims there is a network of organizations that provide social support for HIV/AIDS patients, many of our sources say they have never been to one. Because they are “marked” as HIV positive, many are prevented from pursuing university studies and few can find gainful employment -- many must resort to menial jobs to survive.-- A physician XXXXXXXXXXXX told the FSHP that he works 14 hours every other day, then has to hitchhike home because he cannot afford to own a car.-- XXXXXXXXXXXX stated that Cuban authorities have banned Michael Moore’s documentary, “Sicko,” as being subversive. Although the film’s intent is to discredit the U.S. healthcare system by highlighting the excellence of the Cuban system, he said the regime knows the film is a myth and does not want to risk a popular backlash by showing to Cubans facilities that are clearly not available to the vast majority of them. When the FSHP showed Sicko to a group of XXXXXXXXXXXX, some became so disturbed at the blatant misrepresentation of healthcare in Cuba that they left the room.-- Even the Cuban ruling elite sometimes goes outside of Cuba for the best medical care. Fidel Castro, in July, 2006 brought in a Spanish doctor during his health crisis. Vice Minister of Health Abelardo Ramirez went to France for gastric cancer surgery. The neurosurgeon who is Chief of CIMEQ Hospital (reportedly one of the best in Cuba) went to England for eye surgery and returns periodically for checkups.-- According to a local pediatrician, the approximate breakdown of Cuban physicians’ salaries are: 1st & 2nd year residences earn 325 pesos monthly (USD 15.00); 3rd year residences earn 355 (USD 16.00); 4th year residences (specialists) earn 400 pesos monthly (USD 18.00). For every four years of medical practice thereafter, a physician receives an additional 20 pesos (USD 0.89 cents) per month.-- There is reportedly such a shortage of nurses that within the last few years, a high-school graduate is now offered anHAVANA 00000103 003 OF 006accelerated training course of just ten-months duration entitled, “Enfermeras Emergentes” (Emergency Nurses). These “quasi” nurses are not trained to start Intravenous lines, interpret lab results or draw blood.-- Few medical professionals are allowed access to the internet and are rarely allowed to travel to participate in international conferences or continuing education courses. Access to up-to-date medical literature is not available. Some physicians have confided to the FSHP, “All of us want to leave.” They are dissatisfied with their salaries and their own medical care. They receive no special privileges - most of them do not even have access to care at the better foreigner hospitals, even if they work there.-- As described in reftel, the best medical institutions in Cuba are reserved for foreigners with hard currency, members of the ruling elite and high-ranking military personnel. These institutions, with their intended patient clientele in parentheses, include: Clinica Central Cira Garcia (diplomats & tourists), Centro Internacional de Investigaciones Restauracion Neurologica (foreigners & military elite), Centro de Investigaciones Medico Quirurgicas (military & regime elite), Clinica de Kohly (Primer Buro Politico & Generals of the Ministry of Interior), and the top floors of the Hermanos Ameijeiras Hospital (foreigners) and Frank Pais Hospital (foreigners). These institutions are hygienically qualified, and have a wide array of diagnostic equipment with a full complement of laboratories, well-stocked pharmacies, and private patient suites with cable television and bathrooms.¶4. (C) Below are first-hand observations from USINT’s Foreign Service Health Practitioner’s (FSHP) impromptu and unauthorized (by the GOC) visits to major Havana hospitals where average Cubans receive their healthcare, and from conversations with Cubans in many walks of life.¶A. Hermanos Ameijeiras Hospital-- Address: San Lazaro #701 Esquina A Belascoain, Centro Habana, Havana-- Date of visit: October, 2007-- Built in 1982, this newly renovated 600 bed, 24 story hospital is depicted in Michael Moore’s film “Sicko,” where some 60 surgeries are performed daily including heart, kidney, and cornea transplants, mostly to patients who receive free treatment as part of Operation Milagro (mostly from Venezuela, but also from the rest of Latin America). The two top floors (shown in the movie) are the most modern and are reserved for medical tourists and foreign diplomats who pay in hard currency. The hospital has three intensive care units and all medical specialties except Pediatrics and Obstetrics/Gynecology and has no emergency room. The facility has a CT scanner (often said to be out-of-service), MRI and hyperbaric chamber capabilities.-- Upon entering the building the FSHP was struck by the grand and impressive lobby with a four-story ceiling, polished terrazzo floors and an elegant center reception booth. No one was in the reception booth, which displayed a digital streaming ticker-tape announcing an outdated hospital event; 30 or 40 people were sparsely scattered in the leather-like chairs throughout the lobby. There were no wheel chairs or other obvious signs this was a hospital.-- She was told the majority of patients came from Venezuela and each received weekly one bar of Palmolive bath soap, Palmolive shampoo, and a tube of Colgate toothpaste. She was also told the Venezuelan patients frequently take these items outside to the front parking lot and sell them to local Cubans. Cuban in-patients receive one tube of Colgate toothpaste and no other toiletries.-- Due to the high volume of foreigners receiving treatments and surgeries, most Cubans do not have access - the only chance might be a through a family member or connection working there and a gift or 20 CUCS (USD 21.60) to the Hospital Administrator. Cubans are reportedly very resentfulHAVANA 00000103 004 OF 006that the best hospital in Havana is “off-limits” to them.¶B. Ramon Gonzalez Coro Hospital-- Address: Calle 21 #856 between 4th & 6th Avenues, Vedado Plaza, Havana-- Date of visit: July, 2006-- What is today the Obstetrics & Gynecology (OB-Gyn) hospital for Havana, used to be a private clinic prior to the revolution. The hospital has: 300 beds and reserves 12 beds for foreigners; an Intensive Care Unit for women as well as a Newborn Intensive Care Unit (using a very old infant ‘Bird’ respirator/ventilator - the model used in the U.S. in the 1970s); an Intermediate Newborn Care Unit; one room for babies less than five pounds needing weight gain; a Genetics Department with a specialized laboratory; and five surgical suites.-- The FSHP visited this hospital with a pregnant USINT American patient. Normally USINT staff is required to go to Cira Garcia Clinic, but because there were possible OB complications the FSHP was able to arrange, through a Cuban medical contact, for the patient to be seen by a highly-recommended obstetrician.-- This hospital, located in the densely populated residential area of Vedado, had a dilapidated and crumbling exterior. The FSHP was stopped at the entrance by a guard, but upon mentioning the name of the doctor they were to see, were allowed to proceed to the second floor - supposedly the nicest part of the hospital, which is reserved for foreigners; it reminded the FSHP of some of the poorest hospitals she had seen in Africa - unkempt rooms, old wrought-iron beds, flat mattresses with only one sheet, no A/C, no TV, no amenities. At the nursing station there was no nurse, but a metal cabinet with glass doors that had one jar filled with cotton and one half-full 16 ounce bottle of isopropyl alcohol. There were no other supplies nor any indication this was a nurse’s station - no stethoscopes, no computers, no medical charts, no papers or pens on the desk - there was a lone dial-type black telephone.-- After waiting 15 minutes a nurse in a white uniform appeared and told the FSHP and her patient to wait. She wasn’t friendly. There was no waiting room, so they found some chairs in the hall. It was very hot and the patient was very anxious and in pain. After 45 minutes and several attempts in a polite manner to move things along, a young female doctor came out smiling and asked for the patient - she asked that her husband remain in the chair, but did allow the FSHP to go with her upon insisting. At the end of a long hallway, the FSHP and the patient were guided into an “exam room.” There were no chairs, screens, posters, any medical supplies or equipment; only one old rusting sheet-metal table without any covering, extensions or stirrups. She asked the patient to undress and climb on the table with no intention to drape her. Having worked in third-world countries, the FSHP brought with her a bag of supplies that included paper drapes, which she placed on the table and over the patient. The doctor pulled out of a nearby drawer an old Pinard fetal heart stethoscope made of aluminum (funnel-shaped, like those used at the turn of the Century ) to listen for the baby’s heart beat. The FSHP could not believe her eyes -- this was one of the best OB/GYN hospitals in Cuba. When the FSHP offered the doctor a portable fetal Doppler she had brought from the USINT Health Unit (HU), she gladly accepted.-- Although the doctor appeared to be clinically competent, she was abrupt and rough with the patient. FSHP believes this to be typical of the hierarchical doctor-patient relationship in Cuba. She stated, “She has an infection and needs an antibiotic,” and gave the FSHP a written prescription for an antibiotic generally not recommended during pregnancy. Upon returning to the HU the FSHP did a culture that returned negative for a bacterial infection. Needless to say, the FSHP did not give the prescription to the patient. As a result of this experience, the FSHP concluded that the best care for her unstable female pregnant patients in Havana -- barring a MEDEVAC to the U.S. -- wouldHAVANA 00000103 005 OF 006be by the FSHP in their own home with telephone consults to an obstetrician in the U.S.-- XXXXXXXXXXXX told the FSHP that XXXXXXXXXXXX foreign medical students are increasingly covering for the gross shortages of physicians in Cuban hospitals.¶C. Calixto Garcia Hospital-- Address: Avenida De Universidad Y 27 De Noviembre, Vedado, Havana-- Date of visit: November, 2007-- Built in the late 1800’s, this dilapidated 400-bed hospital was the first teaching hospital in Cuba and is only for Cubans. FSHP believes that if Michael Moore really wanted the “same care as local Cubans,” this is where he should have gone. The 22-bed emergency room receives all the major trauma and accident victims from Havana City, plus there are large Intensive and Intermediate Care Units. It also has a CT scanner and an MRI, which are reportedly often out of order. The hospital provides specialist care in all medical fields except OB-Gyn and Pediatrics.-- During the hospital visit, FSHP was struck by the shabbiness of the facility -- no renovations were apparent -- and the lack of everything (medical supplies, privacy, professional care staff). To the FSHP it was reminiscent of a scene from some of the poorest countries in the world.-- In an open-curtained exam room inside the emergency room, FSHP saw a middle-aged man lying on a gurney in his own soiled clothes with a large bloody bandage wrapped around his head - he was breathing, but was neither moving nor talking - there was no IV, oxygen (in fact no piped-in oxygen at all at this facility) or monitoring equipment. Neither did there seem to be any sense of urgency to his care.-- The hospital is spread out over several city blocks consisting of many two-story buildings with various specialties: Internal Medicine, Cardiology, General Surgery, Orthopedics, Ophthalmology, and Neurology, etc. Each building is set up in dormitory style, with 44 metal beds in two large open rooms.-- The laboratory equipment is very rudimentary - a simple CBC (complete blood count) blood test is calculated manually by a laboratory technician looking through a microscope and counting the individual leucocytes, lymphocytes, monocytes, etc.-- As the FSHP exited a building, XXXXXXXXXXXX drove up in a badly dented 1981 Moskovich that belched exhaust fumes. The private car, which is a luxury in Cuba, was a gift from his deceased father. He was a thin man, appearing disheveled, unshaved, with a cigarette between his lips, wearing a tattered white lab coat without a shirt underneath. He said his salary was 565 pesos (approximately $22) per month.¶D. Salvador Allende Hospital-- Address: Calzada Del Cerro # 1551, Cerro, Havana-- Date of visit: November, 2007-- This 400-bed hospital is located in Cerro - a poorer and more densely populated section than the others visited in Havana. It is an old, run-down facility similar in appearance to Calixto Garcia Hospital in that there are several two-story buildings each with a medical specialty.-- The FSHP was dropped off a few blocks away so the guards wouldn’t see the diplomatic plates. When she walked in, the guards smelled of alcohol. In the emergency room there were about 40 mostly poor-looking Afro-Cuban patients waiting toHAVANA 00000103 006 OF 006be seen. It appeared to be very orderly, clean, and organized.-- The rest of the buildings were in shambles . The FSHP did not see any “real” medicine or nursing practiced during her almost one-hour walk through most of the buildings. As she saw patients, she could not help but think that their own home might provide more value-added than remaining in that hospital. Patients had to bring their own light bulbs if they wanted light in their rooms. The switch plates and knobs had been stolen from most of the rooms so one had to connect bare wires to get electricity. There was no A/C and few patients had floor fans. Patients had to bring their own sheets, towels, soap and supplemental foods. Hospital food service consisted of rice, fish, rice, eggs, and potatoes day after day. No fresh fruits, vegetables, or meat were available.¶5. (C) Comment: After living in Cuba for two and a half years, treating numerous Cuban employees at USINT, and interacting with many other Cubans, the FSHP believes many are malnourished and psychologically stressed. Hypertension, diabetes and asthma are widespread, but poorly treated. Common prescription and basic over-the-counter medications are unavailable. Given the large number of chronic diseases treated by the FSHP, preventive medicine in Cuba is a by-gone ideal, rather than the standard practice of care. PARMLY